Chapter 66; Brunner headache seizures Flashcards
A patient with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate?
A)
Restrain the patient to prevent injury.
B)
Open the patient’s jaws to insert an oral airway.
C)
Place patient in high Fowler’s position.
D)
Loosen the patient’s restrictive clothing.
Ans:
D
Feedback:
An appropriate nursing intervention would include loosening any restrictive clothing on the patient. No attempt should be made to restrain the patient during the seizure because muscular contractions are strong and restraint can produce injury. Do not attempt to pry open jaws that are clenched in a spasm to insert anything. Broken teeth and injury to the lips and tongue may result from such an action. If possible, place the patient on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus.
A patient who has been on long-term phenytoin (Dilantin) therapy is admitted to the unit. In light of the adverse of effects of this medication, the nurse should prioritize which of the following in the patient’s plan of care?
A)
Monitoring of pulse oximetry
B)
Administration of a low-protein diet
C)
Administration of thorough oral hygiene
D)
Fluid restriction as ordered
Ans:
C
Feedback:
Gingival hyperplasia (swollen and tender gums) can be associated with long-term phenytoin (Dilantin) use. Thorough oral hygiene should be provided consistently and encouraged after discharge. Fluid and protein restriction are contraindicated and there is no particular need for constant oxygen saturation monitoring.
A nurse is admitting a patient with a severe migraine headache and a history of acute coronary syndrome. What migraine medication would the nurse question for this patient?
A)
Rizatriptan (Maxalt)
B)
Naratriptan (Amerge)
C)
Sumatriptan succinate (Imitrex)
D)
Zolmitriptan (Zomig)
Ans:
C
Feedback:
Triptans can cause chest pain and are contraindicated in patients with ischemic heart disease. Maxalt, Amerge, and Zomig are triptans used in routine clinical use for the treatment of migraine headaches.
The nurse is caring for a patient with increased intracranial pressure (ICP). The patient has a nursing diagnosis of “ineffective cerebral tissue perfusion.” What would be an expected outcome that the nurse would document for this diagnosis?
A)
Copes with sensory deprivation.
B)
Registers normal body temperature.
C)
Pays attention to grooming.
D)
Obeys commands with appropriate motor responses.
Ans:
D
Feedback:
An expected outcome of the diagnosis of ineffective cerebral tissue perfusion in a patient with increased intracranial pressure (ICP) would include obeying commands with appropriate motor responses. Vitals signs and neurologic status are assessed every 15 minutes to every hour. Coping with sensory deprivation would relate to the nursing diagnosis of “disturbed sensory perception.” The outcome of “registers normal body temperature” relates to the diagnosis of “potential for ineffective thermoregulation.” Body image disturbance would have a potential outcome of “pays attention to grooming.”
While completing a health history on a patient who has recently experienced a seizure, the nurse would assess for what characteristic associated with the postictal state?
A)
Epileptic cry
B)
Confusion
C)
Urinary incontinence
D)
Body rigidity
Ans:
B
Feedback:
In the postictal state (after the seizure), the patient is often confused and hard to arouse and may sleep for hours. The epileptic cry occurs from the simultaneous contractions of the diaphragm and chest muscles that occur during the seizure. Urinary incontinence and intense rigidity of the entire body are followed by alternating muscle relaxation and contraction (generalized tonic–clonic contraction) during the seizure.
The nurse is caring for a patient who is in status epilepticus. What medication does the nurse know may be given to halt the seizure immediately?
A)
Intravenous phenobarbital (Luminal)
B)
Intravenous diazepam (Valium)
C)
Oral lorazepam (Ativan)
D)
Oral phenytoin (Dilantin)
Ans:
B
Feedback:
Medical management of status epilepticus includes IV diazepam (Valium) and IV lorazepam (Ativan) given slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are given later to maintain a seizure-free state. Oral medications are not given during status epilepticus.
clinic nurse is caring for a patient diagnosed with migraine headaches. During the patient teaching session, the patient questions the nurse regarding alcohol consumption. What would the nurse be correct in telling the patient about the effects of alcohol?
A)
Alcohol causes hormone fluctuations.
B)
Alcohol causes vasodilation of the blood vessels.
C)
Alcohol has an excitatory effect on the CNS.
D)
Alcohol diminishes endorphins in the brain.
Ans:
B
Feedback:
Alcohol causes vasodilation of the blood vessels and may exacerbate migraine headaches. Alcohol has a depressant effect on the CNS. Alcohol does not cause hormone fluctuations, nor does it decrease endorphins (morphine-like substances produced by the body) in the brain.
The nurse is providing care for a patient who is withdrawing from heavy alcohol use. The nurse and other members of the care team are present at the bedside when the patient has a seizure. In preparation for documenting this clinical event, the nurse should note which of the following?
A)
The ability of the patient to follow instructions during the seizure.
B)
The success or failure of the care team to physically restrain the patient.
C)
The patient’s ability to explain his seizure during the postictal period.
D)
The patient’s activities immediately prior to the seizure.
Ans:
D
Feedback:
Before and during a seizure, the nurse observes the circumstances before the seizure, including visual, auditory, or olfactory stimuli; tactile stimuli; emotional or psychological disturbances; sleep; and hyperventilation. Communication with the patient is not possible during a seizure and physical restraint is not attempted. The patient’s ability to explain the seizure is not clinically relevant.
A patient has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize?
A)
Unclassified seizure
B)
Absence seizure
C)
Generalized seizure
D)
Focal seizure
Ans:
C
Feedback:
Generalized seizures often involve both hemispheres of the brain, causing both sides of the body to react. Intense rigidity of the entire body may occur, followed by alternating muscle relaxation and contraction (generalized tonic–clonic contraction). This pattern of rigidity does not occur in patients who experience unclassified, absence, or focal seizures.
A patient is recovering from intracranial surgery performed approximately 24 hours ago and is complaining of a headache that the patient rates at 8 on a 10-point pain scale. What nursing action is most appropriate?
A)
Administer morphine sulfate as ordered.
B)
Reposition the patient in a prone position.
C)
Apply a hot pack to the patient’s scalp.
D)
Implement distraction techniques.
Ans:
A
Feedback:
The patient usually has a headache after a craniotomy as a result of stretching and irritation of nerves in the scalp during surgery. Morphine sulfate may also be used in the management of postoperative pain in patients who have undergone a craniotomy. Prone positioning is contraindicated due to the consequent increase in ICP. Distraction would likely be inadequate to reduce pain and a hot pack may cause vasodilation and increased pain.
A school nurse is called to the playground where a 6-year-old girl has been found unresponsive and “staring into space,” according to the playground supervisor. How would the nurse document the girl’s activity in her chart at school?
A)
Generalized seizure
B)
Absence seizure
C)
Focal seizure
D)
Unclassified seizure
Ans:
B
Feedback:
Staring episodes characterize an absence seizure, whereas focal seizures, generalized seizures, and unclassified seizures involve uncontrolled motor activity.
A neurologic nurse is reviewing seizures with a group of staff nurses. How should this nurse best describe the cause of a seizure?
A)
Sudden electrolyte changes throughout the brain
B)
A dysrhythmia in the peripheral nervous system
C)
A dysrhythmia in the nerve cells in one section of the brain
D)
Sudden disruptions in the blood flow throughout the brain
Ans:
C
Feedback:
The underlying cause of a seizure is an electrical disturbance (dysrhythmia) in the nerve cells in one section of the brain; these cells emit abnormal, recurring, uncontrolled electrical discharges. Seizures are not caused by changes in blood flow or electrolytes.
The nurse is caring for a patient who has undergone supratentorial removal of a pituitary mass. What medication would the nurse expect to administer prophylactically to prevent seizures in this patient?
A)
Prednisone
B)
Dexamethasone
C)
Cafergot
D)
Phenytoin
Ans:
D
Feedback:
Antiseizure medication (phenytoin, diazepam) is often prescribed prophylactically for patients who have undergone supratentorial craniotomy because of the high risk of seizures after this procedure. Prednisone and dexamethasone are steroids and do not prevent seizures. Cafergot is used in the treatment of migraines.
A hospital patient has experienced a seizure. In the immediate recovery period, what action best protects the patient’s safety?
A)
Place the patient in a side-lying position.
B)
Pad the patient’s bed rails.
C)
Administer antianxiety medications as ordered.
D)
Reassure the patient and family members.
Ans:
A
Feedback:
To prevent complications, the patient is placed in the side-lying position to facilitate drainage of oral secretions. Suctioning is performed, if needed, to maintain a patent airway and prevent aspiration. None of the other listed actions promotes safety during the immediate recovery period.
A nurse is caring for a patient who experiences debilitating cluster headaches. The patient should be taught to take appropriate medications at what point in the course of the onset of a new headache?
A)
As soon as the patient’s pain becomes unbearable
B)
As soon as the patient senses the onset of symptoms
C)
Twenty to 30 minutes after the onset of symptoms
D)
When the patient senses his or her symptoms peaking
Ans:
B
Feedback:
A migraine or a cluster headache in the early phase requires abortive medication therapy instituted as soon as possible. Delaying medication administration would lead to unnecessary pain.
